The Spanish Society of Paediatric Infectious Diseases guidelines on the prevention, diagnosis and treatment of neonatal herpes simplex infections

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Previamente a la aplicación de este algoritmo hay que asegurarse junto con el microbiólogo de la disponibilidad de las técnicas y que los tiempos de respuesta son adecuados. ¥El estudio diagnóstico y el tratamiento se realizarán previamente en caso de que el recién nacido presente signos de infección por VHS. Algunos expertos recomiendan la realización de tomas de muestras y el inicio de tratamiento de forma inmediata tras el parto en caso de rotura prolongada de membranas y en el caso de recién nacidos prematuros. $Si el recién nacido se encuentra asintomático y la PCR es negativa, se puede valorar el alta hospitalaria a las 48h si hay condiciones adecuadas para una vigilancia domiciliaria y de acceso inmediato al hospital." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "" "autores" => array:1 [ 0 => array:1 [ "colaborador" => "Grupo de Trabajo de Infección Neonatal por virus herpes simplex de la Sociedad Española de Infectología Pediátrica" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341287918300887" "doi" => "10.1016/j.anpede.2018.01.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" 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"Spanish Association of Paediatrics" "titulo" => "The Spanish Society of Paediatric Infectious Diseases guidelines on the prevention, diagnosis and treatment of neonatal herpes simplex infections" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "64.e1" "paginaFinal" => "64.e10" ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "" "autores" => array:1 [ 0 => array:2 [ "colaborador" => "Working Group on Neonatal Infection by Herpes Simplex Virus of the Sociedad Española de Infectología Pediátrica" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "◊" "identificador" => "fn0005" ] ] ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guía de la Sociedad Española de Infectología Pediátrica sobre prevención, diagnóstico y tratamiento de la infección neonatal por virus herpes simplex" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 855 "Ancho" => 2503 "Tamanyo" => 276063 ] ] "descripcion" => array:1 [ "en" => "Management of asymptomatic newborns delivered vaginally or by caesarean section and with mothers with genital lesions at the time of delivery. Before implementing this algorithm, the clinician should verify in collaboration with the microbiologist that the necessary techniques are available and the turnaround times are adequate. ¥The diagnostic evaluation and treatment will be performed earlier if the newborn presents signs of infection by HSV. Some experts recommend collection of specimens and initiation of treatment immediately after delivery in case of prolonged rupture of membranes or preterm birth. $If the newborn is asymptomatic and the results of PCR negative, discharge at 48h post birth can be considered if the necessary conditions are met for adequate monitoring at home and immediate access to the hospital." ] ] ] "textoCompleto" => "IntroductionInfection by herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) is highly prevalent worldwide and encompasses a broad range of pathology. Up to 67% of the global population is infected by one of these two viruses.<a class="elsevierStyleCrossRef" href="#bib0205">1</a>The first episode of genital infection is labelled primary genital herpes (GH) and may be caused by HSV-1 or HSV-2. When an additional episode is caused by the other type, it is referred to as non-primary first episode GH. New episodes by the same type of the virus are known as recurrent GH.These viruses may be vertically transmitted to the newborn. Neonatal herpes infection (neonatal herpes [NH]) is rare, but it must be diagnosed correctly and treated at an early stage. In recent years, there have been advances in the diagnosis and treatment of this disease, so this document provides and updated guideline for its multidisciplinary management.EpidemiologyGenital herpesThe type involved most frequently in GH worldwide is HSV-2. The prevalence of HSV-1 is increasing in many countries, such as the United States, where it is now the most frequent cause of new cases of GH.<a class="elsevierStyleCrossRef" href="#bib0210">2</a>In Spain, the incidence of genital infections by HSV has increased in recent years.<a class="elsevierStyleCrossRef" href="#bib0215">3</a> Type 2 has been historically the type isolated most frequently from genital samples,<a class="elsevierStyleCrossRef" href="#bib0220">4</a> a trend that continues today.<a class="elsevierStyleCrossRefs" href="#bib0215">3,5</a> The seroprevalence of HSV-2 infection in adults is 5–10%.<a class="elsevierStyleCrossRefs" href="#bib0215">3,5</a>The risk factors for GH include: female sex, low socioeconomic status, genital coinfection, years of sexual activity and large number of sexual partners. Based on data from the medical literature of the United States, the overall risk of having a first episode of GH during pregnancy is 4%.<a class="elsevierStyleCrossRef" href="#bib0230">6</a> Also, of all pregnant women with a previous history of symptomatic GH by HSV-2, 75% have at least one episode of recurrent GH during pregnancy.<a class="elsevierStyleCrossRef" href="#bib0235">7</a> The risk of recurrence is lower in women with GH caused by HSV-1.The identification of NH is frequently challenging. In up to 80% of cases of mother-to-child vertical transmission, there is no previous history of GH,<a class="elsevierStyleCrossRef" href="#bib0230">6</a> although genital viral shedding around the time of delivery, whether symptomatic or asymptomatic, is necessary for transmission. Between 0.2% and 0.39% of pregnant women shed HSV in the genital region during the peripartum period, independently of their personal history of GH, and this prevalence increases to 0.77–1.4% in women with a history of recurrent GH.<a class="elsevierStyleCrossRef" href="#bib0235">7</a> Viral shedding usually lasts 2 or 3 weeks after a primary GH episode, although it can persist for up to 2 or 3 months, is shorter in non-primary GH episodes, and intermittent in recurrent episodes.Neonatal herpesNeonatal herpes is rare in developed countries, with an incidence that ranges between 1.65 and 3.2 cases per 100000 live births in European countries like the Netherlands or Switzerland.<a class="elsevierStyleCrossRef" href="#bib0235">7</a> In other countries there has been a recent increase in incidence, for instance, the incidence in the United Kingdom recently reached 17.5 cases per 100000 births.<a class="elsevierStyleCrossRef" href="#bib0240">8</a> For reasons that remain unclear, the incidence of NH has historically been greater in the United States compared to the European average, ranging between 4 and 33 cases per 100000 live births.<a class="elsevierStyleCrossRef" href="#bib0230">6</a>Both HSV-1 and HSV-2 cause disease in the neonatal period, although the proportion of cases caused by either virus varies between case series, reflecting the epidemiology of GH in the geographical area or the time period of the study. Type 2 is the most frequent cause of NH in developing countries.<a class="elsevierStyleCrossRef" href="#bib0205">1</a> The incidence of HSV-1 has increased in developed countries, and HSV-1 is now the most prevalent cause of NH in some countries, including Australia and the United States.<a class="elsevierStyleCrossRef" href="#bib0245">9</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the risk factors for NH.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Infection by herpes simplex virus during pregnancyThe diagnosis of GH in pregnant women is based on history taking and a physical examination, and it must be confirmed by laboratory tests.Clinical pictureThe clinical picture is characterised by the formation of lesions (vesicles that progress to pustules and eventually ulcers), usually painful, in the genital tract and adjacent areas. Primary infection may manifest with general malaise, dysuria and inguinal lymphadenopathy. However, the first episode of GH may be asymptomatic in up to 2/3 of women. The presentation of recurrent GH is milder, although it is usually preceded by prodromal manifestations such as genital itching, burning or pain.Laboratory diagnosisFirst episode of genital herpes during pregnancyFirst episodes of GH can be primary or non-primary. Viral detection tests by polymerase chain reaction (PCR) should be performed in samples of ulcer secretions or vesicle fluid collected by swabbing. Polymerase chain reaction is sensitive enough for testing of samples from any type of lesion and is currently the gold standard where available.<a class="elsevierStyleCrossRef" href="#bib0260">12</a> The technique used should be type-specific PCR (for HSV-1 and -2). Serological tests for HSV (specific antibodies to HSV-1 and 2) at the time of diagnosis allows the classification of maternal GH infection into primary, first-episode non-primary or recurrent infection (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#bib0265">13</a> It may take up to 6 weeks from primary infection for IgG antibodies to become detectable. Serological testing for detection of IgM antibodies is not recommended in clinical practice.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In women with genital ulcers that are highly suggestive of GH but with negative HSV PCR results, antibody testing should be repeated 6 weeks later. If testing evinces seroconversion, the episode should be diagnosed as primary infection. If testing does not reveal seroconversion, it is unlikely that the ulcer was caused by GH.Pregnant women with recurrent genital herpesIn women with a previous history of confirmed GH (PCR), further diagnostic testing is unnecessary. There is no evidence that repeated testing by PCR to detect asymptomatic shedding during pregnancy or at the time of delivery helps prevent vertical transmission, and this strategy is therefore not indicated.<a class="elsevierStyleCrossRef" href="#bib0270">14</a>However, if a pregnant woman has compatible lesions and reports a history of previous episodes but these episodes were not confirmed by diagnostic tests, performance of PCR and antibody tests is indicated to confirm the diagnosis.Treatment of herpes simplex virus infection during pregnancy. Strategies for prevention of mother-to-child transmission (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>)The main goal of GH treatment during pregnancy is prevention of mother-to-child transmission. The best measures currently available to this end are caesarean delivery in mothers that have herpetic lesions and the reduction of viral shedding by administration of antiviral agents to pregnant women with active GH in the last few weeks of pregnancy. The FDA has classified acyclovir and valacyclovir as category B drugs, but their use is considered safe in any trimester of gestation.<a class="elsevierStyleCrossRef" href="#bib0275">15</a> Since there is less evidence on valacyclovir, some guidelines recommend avoiding this drug in the first trimester.<a class="elsevierStyleCrossRef" href="#bib0270">14</a> Suppressive therapy has proven effective in reducing recurrence and the need for caesarean delivery, although the evidence published to date has not demonstrated a reduction in the risk of NH<a class="elsevierStyleCrossRef" href="#bib0280">16</a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Primary genital herpes during gestation<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Treatment: Oral acyclovir at 400mg every 8h or oral valacyclovir at 1g every 12h for 7–10 days.<a class="elsevierStyleCrossRefs" href="#bib0270">14,17</a></li><li class="elsevierStyleListItem" id="lsti0010">•Route of delivery: Whenever primary HSV infection is diagnosed during labour, a caesarean delivery will be performed as soon as possible, regardless of the duration of amniorrhexis. An elective caesarean delivery will be performed in every pregnant woman that has a primary episode of GH within 6 weeks from delivery.<a class="elsevierStyleCrossRefs" href="#bib0270">14,17,18</a></li></ul>Recurrent genital herpes during gestation<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">•Treatment: Consider administration of oral acyclovir at 400mg every 8h or oral valacyclovir at 500mg every 12h for 3–5 days. In general, treatment is only necessary if the mother has significant symptoms or if the lesions appear when the time of delivery is approaching.<a class="elsevierStyleCrossRefs" href="#bib0270">14,17,18</a></li><li class="elsevierStyleListItem" id="lsti0020">•Route of delivery: Elective caesarean delivery is only indicated in patients that have an outbreak or prodromal symptoms during labour, regardless of the duration of amniorrhexis. An episode of GH at any other time of the pregnancy is not an indication for caesarean delivery. In case of vaginal delivery, invasive procedures (such as continuous foetal heart rate monitoring with scalp electrodes or foetal blood microsampling) and prolonged rupture of membranes should be avoided.</li></ul>Suppressive therapyIn pregnant women with a first episode of GH (primary or non-primary) or with recurrent GH and at least one symptomatic outbreak during pregnancy, suppressive therapy with oral acyclovir at 400mg every 8h or valacyclovir at 500mg every 12h is recommended starting from 36 weeks’ gestation through delivery.<a class="elsevierStyleCrossRefs" href="#bib0270">14,17,18</a> In women at risk of preterm delivery, use of suppressive antivirals may be considered at an earlier gestational age when the risk of preterm birth due to short cervix or dynamic changes is identified.<a class="elsevierStyleCrossRef" href="#bib0290">18</a>Women with HIV infection and a history of GH (even those without episodes during gestation) should be offered suppressive therapy starting at 32 weeks’ gestation due to the increased risk of preterm delivery and of HIV transmission associated with HSV infection.<a class="elsevierStyleCrossRef" href="#bib0270">14</a>Genital herpes in pregnant women with premature rupture of membranes at more than 37 weeks’ gestation<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025">•In cases of maternal primary infection, the risk of NH is very high, but there is little evidence on the optimal management of these cases. The management will be individualised and based on gestational age. If the decision is to end the pregnancy immediately, the child will be delivered by caesarean section. If a watchful waiting approach is chosen, the mother will be given intravenous acyclovir (5mg/kg every 8h) for a maximum of 7–10 days, and suppressive therapy until delivery may be considered. If the time elapsed between onset of GH and delivery is less than 6 weeks, delivery by caesarean section is preferable.<a class="elsevierStyleCrossRefs" href="#bib0270">14,17</a></li><li class="elsevierStyleListItem" id="lsti0030">•In cases of maternal recurrent infection, the mother will receive oral antiviral therapy and the followup will be the same as would be in case of premature rupture of membranes. If the lesions have not resolved by the time ending the pregnancy is indicated, the child will be delivered by caesarean section.<a class="elsevierStyleCrossRefs" href="#bib0270">14,17</a></li></ul>Neonatal herpes: disease forms<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> describes the 3 forms of NH associated to perinatal and postnatal infection. This classification has significant implications for treatment, and each of the forms has a different prognosis.Diagnosis of infection in the newbornThe initial manifestations of NH may be subtle and nonspecific. Its presentation may be confused with other diseases, mainly bacterial infections (sepsis or meningitis) or viral infections (especially infection by enterovirus or parechovirus). Early diagnosis and treatment of NH requires a high level of suspicion, especially in the absence of skin lesions. We recommend ruling out NH infection in newborns with lesions in the skin or mucosae, central nervous system (CNS) involvement or a sepsis-like picture of unexplained aetiology.When NH is suspected, the newborn should undergo comprehensive viral testing (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The confirmation of the diagnosis through laboratory methods mainly involves the detection of HSV by PCR.Polymerase chain reaction for detection of HSV in cerebrospinal fluid (CSF) is the gold standard for diagnosis due to the higher sensitivity of viral culture of this type of sample. In the current literature, the reported sensitivity of PCR for detection of HSV in CSF ranges between 75% and 100%, while the reported specificity between ranges between 71% and 100%.<a class="elsevierStyleCrossRefs" href="#bib0330">26,27</a> In clinical practice, false positives for HSV are extremely rare. Polymerase chain reaction for detection of HSV in blood samples is also highly sensitive and is recommended for the diagnostic evaluation of newborns with suspected NH of any form.<a class="elsevierStyleCrossRef" href="#bib0340">28</a>Lumbar puncture should be performed in every newborn with suspected NH, even in cases where isolated skin involvement is likely. The presence of blood or elevated protein levels in CSF may interfere with PCR and lead to false negative results. Polymerase chain reaction may also yield false negative results if lumbar puncture is performed in the early stages of disease (first 3 days) or after several days of antiviral therapy. If the initial PCR test is negative and CNS involvement is suspected, a repeat PCR should be performed in the first week since onset, and antiviral therapy maintained until the results become available.The characteristic findings of CSF analysis are pleocytosis with a predominance of mononuclear cells and moderate elevation of protein and glucose levels. The findings of CSF analysis may be normal in the early stages of CNS involvement. The presence of red blood cells in CSF does not seem characteristic of HSV-related neonatal meningoencephalitis.Neuroimaging tests should be performed in every newborn with NH, and the gold standard is magnetic resonance imaging (MRI). Involvement is usually diffuse in newborns with HSV encephalitis. The usual course of CNS involvement is oedema that progresses to cystic encephalomalacia. Neuroimaging findings may be normal at first, and diffusion-weighted MRI is the most sensitive technique for the early detection of CNS changes. Magnetic resonance imaging can be used on completion of antiviral treatment to assess the level of brain damage. The diagnostic yield of computed tomography is lower compared to MRI. Head ultrasound offers the advantage of allowing followup through serial examinations.Although regular or nearly regular focal or multifocal epileptiform discharges are the typical encephalographic presentation, the encephalographic pattern in the acute phase of neonatal encephalitis due to HSV can include a variety of features.<a class="elsevierStyleCrossRef" href="#bib0345">29</a> The presence of focal or unilateral abnormalities associated to clinical signs of encephalitis is highly suggestive of HSV infection.The evaluation of the extent of dissemination is key to provide adequate treatment in the early stages of disease (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Chest radiography may reveal lung involvement, characterised by a diffuse interstitial pattern that may progress to pneumonitis with alveolar haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0350">30</a> In cases of hepatitis, abdominal ultrasound may reveal hepatomegaly with fine nodular patterns in the liver parenchyma, splenomegaly, signs of portal hypertension and ascites.<a class="elsevierStyleCrossRef" href="#bib0355">31</a>TreatmentTreatment of acute infectionTreatment of NH includes the usual life support measures used in any septic process in newborns, management of potential complications (seizures, in which it is essential to avoid hypoglycaemia, disseminated intravascular coagulation, bacterial superinfection, etc.) and antiviral therapy. High-dose acyclovir (20mg/kg every 8h, intravenously, adjusted based on renal function) is the first-line antiviral for all forms of disease.<a class="elsevierStyleCrossRefs" href="#bib0310">22,24,32</a>In most cases, clinical suspicion of infection by HSV is sufficient indication for treatment. Early initiation of acyclovir improves morbidity and mortality outcomes for HSV infection. We recommend monitoring renal function and neutrophil counts during treatment. In cases where acyclovir is contraindicated, ganciclovir of foscarnet can be used, also delivered intravenously.Treatment should last 14 days in the skin, eyes and mouth form and 21 days in cases of localised CNS involvement or disseminated disease. Treatment may be discontinued after the patient shows a favourable response, although in cases of CNS involvement, PCR should be performed to verify negativization, which is usually accompanied by the normalisation of the CNS analysis findings. In case the virus is detected in CSF, treatment with acyclovir will continue accompanied by weekly testing of the CSF, and suspended once the PCR results become negative.<a class="elsevierStyleCrossRef" href="#bib0360">32</a> Some authors consider plasma viral levels undetectable by PCR a marker of resolution in severe or disseminated forms of disease, and continued treatment in their patients as long as viral detection tests were positive.<a class="elsevierStyleCrossRef" href="#bib0340">28</a>In case of keratitis and/or conjunctivitis, the patient should also receive topical treatment (idoxuridine 0.1% solution or ganciclovir 0.15% gel). If the patient has with mucocutaneous lesions, adequate contact precautions should be followed throughout the hospital stay.Suppressive treatment. Treatment of recurrent herpesFollowing treatment of acute disease, suppressive therapy with acyclovir is recommended for all forms of disease (300mg/m2/dose given orally every 8h) for a minimum of 6 months.<a class="elsevierStyleCrossRefs" href="#bib0360">32,33</a> The dose must be adjusted as the patient grows, and the neutrophil count must be monitored, with measurements 2 weeks after treatment initiation and monthly thereafter. Most experts recommend temporary discontinuation of suppressive therapy if the neutrophil count is less than 500cells/mm3.Disease recurrence can even occur in the context of suppressive treatment. The current evidence is not sufficient to establish the best course of action in these cases. <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> presents the recommendations of our Working Group.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Management of children exposed to herpes<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> describes the possible scenarios and the protocol for the management of children born to mothers with genital lesions associated with HSV infection at the time of delivery.<a class="elsevierStyleCrossRefs" href="#bib0370">34–36</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Outcomes of neonatal infection. Patient followupThe mortality rate associated with NH is of approximately 0.8 deaths per 100000 live births.<a class="elsevierStyleCrossRef" href="#bib0385">37</a> Mortality has declined significantly after the introduction of antiviral treatment (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>).<a class="elsevierStyleCrossRefs" href="#bib0305">21,29,35</a> Antiviral treatment has not only succeeded in preventing the progression of cutaneous disease, owing to which neurologic outcomes in these patients are currently excellent, but is also associated with significantly improved neurologic outcomes in cases of disseminated disease. The introduction of suppressive therapy has also been a substantial step forward, improving neurologic outcomes in patients with CNS involvement.<a class="elsevierStyleCrossRefs" href="#bib0310">22,24,33,35,38</a><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a> presents the prognostic factors for NH.<elsevierMultimedia ident="tbl0035"></elsevierMultimedia>The main sequelae are neurologic impairment (psychomotor retardation, microcephaly, paresis, spasticity, epilepsy, learning disabilities), ocular impairment (cortical blindness, corneal and chorioretinal scars, optical atrophy, cataracts, acute retinal necrosis and oculomotor disorders) and hearing impairment (neurosensory hearing loss).We recommend that the followup of patients with NH be performed by a multidisciplinary team.<a class="elsevierStyleCrossRefs" href="#bib0365">33,35</a>Recent evidence has emerged that in cases of HSV infection with CNS involvement, the infection can trigger autoimmune encephalopathy, in most cases with presence of anti-N-methyl-d-aspartate receptor antibodies (anti-NMDAr Abs). Up to 20% of relapses in patients with CNS infection by HSV may be immune-mediated.<a class="elsevierStyleCrossRef" href="#bib0400">40</a> The encephalopathy usually develops weeks or months after the acute infection by HSV, and the most frequent feature in young children is choreoathetosis, with other frequent manifestations including decreased level of consciousness and convulsive seizures.<a class="elsevierStyleCrossRef" href="#bib0400">40</a> Patients with this clinical presentation should be assessed with determination of neuronal cell-surface antibodies in serum and CSF (mainly anti-NMDAr Abs). Some authors recommend starting empiric immunotherapy in patients with these symptoms and negative results of CSF PCR for HSV while awaiting the antibody results.<a class="elsevierStyleCrossRef" href="#bib0400">40</a>Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1066018" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1013888" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1066019" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1013887" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0010" "titulo" => "Epidemiology" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Genital herpes" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Neonatal herpes" ] ] ] ] ] 5 => array:3 [ "identificador" => "sec0025" "titulo" => "Infection by herpes simplex virus during pregnancy" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical picture" ] 1 => array:3 [ "identificador" => "sec0035" "titulo" => "Laboratory diagnosis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "First episode of genital herpes during pregnancy" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Pregnant women with recurrent genital herpes" ] ] ] 2 => array:3 [ "identificador" => "sec0050" "titulo" => "Treatment of herpes simplex virus infection during pregnancy. Strategies for prevention of mother-to-child transmission (Table 3)" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Primary genital herpes during gestation" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Recurrent genital herpes during gestation" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Suppressive therapy" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Genital herpes in pregnant women with premature rupture of membranes at more than 37 weeks’ gestation" ] ] ] ] ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Neonatal herpes: disease forms" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Diagnosis of infection in the newborn" ] 8 => array:3 [ "identificador" => "sec0085" "titulo" => "Treatment" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0090" "titulo" => "Treatment of acute infection" ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Suppressive treatment. Treatment of recurrent herpes" ] ] ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Management of children exposed to herpes" ] 10 => array:2 [ "identificador" => "sec0105" "titulo" => "Outcomes of neonatal infection. Patient followup" ] 11 => array:2 [ "identificador" => "sec0110" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-24" "fechaAceptado" => "2018-01-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1013888" "palabras" => array:3 [ 0 => "Neonatal infection" 1 => "Herpes simplex virus" 2 => "Mother-to-child transmission prevention" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1013887" "palabras" => array:3 [ 0 => "Infección neonatal" 1 => "Virus herpes simplex" 2 => "Prevención de la transmisión maternoinfantil" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Neonatal herpes simplex virus infections are rare, but are associated with significant morbidity and mortality. Most newborns acquire herpes simplex virus infection in the peripartum period. For peripartum transmission to occur, women must be shedding the virus in their genital tracts symptomatically or asymptomatically around the time of delivery. There are evidence-based interventions in pregnancy to prevent the transmission to the newborn. Caesarean section should be performed in the presence of herpetic lesions, and antiviral prophylaxis in the last weeks of pregnancy is recommended to suppress genital tract herpes simplex virus at the time of delivery. The diagnosis and early treatment of neonatal herpes simplex virus infections require a high index of suspicion, especially in the absence of skin lesions. It is recommended to rule out herpes simplex virus infections in those newborns with mucocutaneous lesions, central nervous system involvement, or septic appearance. The prognosis of newborns with skin, eye, and/or mouth disease in the high-dose acyclovir era is very good. Antiviral treatment not only improves mortality rates in disseminated and central nervous system disease, but also improves the rates of long-term neurodevelopmental impairment in the cases of disseminated disease. Interestingly, a 6-month suppressive course of oral acyclovir following the acute infection has improved the neurodevelopmental prognosis in patients with CNS involvement." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La infección herpética neonatal es una entidad muy poco frecuente pero que se asocia a una alta morbimortalidad. La mayor parte de los neonatos afectos adquieren la infección por virus herpes simplex en el periodo periparto. Para que ocurra esta transmisión es necesaria la excreción viral genital, con o sin síntomas, alrededor del momento del parto. Existen intervenciones basadas en la evidencia para prevenir la transmisión del virus herpes simplex al recién nacido. La realización de una cesárea en presencia de lesiones herpéticas, y la disminución de la excreción viral administrando en las últimas semanas del embarazo tratamiento antiviral a gestantes con herpes genital activo, son las mejores medidas preventivas de las que se dispone. El diagnóstico y tratamiento precoz del herpes neonatal requiere de un alto índice de sospecha, sobre todo en ausencia de lesiones cutáneas. Se recomienda descartar la infección por herpes neonatal en aquellos recién nacidos con lesiones cutaneomucosas, afectación del sistema nervioso central o cuadro séptico de origen no aclarado. El pronóstico de los neonatos con enfermedad cutánea en la era del aciclovir a dosis altas es excelente. El tratamiento antiviral disminuye la mortalidad de las formas diseminadas y con afectación exclusiva del sistema nervioso central, pero también mejora el pronóstico neurológico en los casos de enfermedad diseminada. De forma notable, la introducción del tratamiento supresor con aciclovir oral durante los meses siguientes a la infección aguda ha mejorado el pronóstico neurológico en los pacientes con afectación del sistema nervioso central." ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "<a class="elsevierStyleCrossRef" href="#sec0115">Appendix A</a> lists the names of all the authors of the article." "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Grupo de Trabajo de Infección Neonatal por virus herpes simplex de la Sociedad Española de Infectología Pediátrica. Guía de la Sociedad Española de Infectología Pediátrica sobre prevención, diagnóstico y tratamiento de la infección neonatal por virus herpes simplex. An Pediatr (Barc). 2018;89:64." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Coordinators (in alphabetical order) Writers (in alphabetical order)" "etiqueta" => "Appendix A" "titulo" => "Authors of the article" "identificador" => "sec0115" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 855 "Ancho" => 2503 "Tamanyo" => 276063 ] ] "descripcion" => array:1 [ "en" => "Management of asymptomatic newborns delivered vaginally or by caesarean section and with mothers with genital lesions at the time of delivery. Before implementing this algorithm, the clinician should verify in collaboration with the microbiologist that the necessary techniques are available and the turnaround times are adequate. ¥The diagnostic evaluation and treatment will be performed earlier if the newborn presents signs of infection by HSV. Some experts recommend collection of specimens and initiation of treatment immediately after delivery in case of prolonged rupture of membranes or preterm birth. $If the newborn is asymptomatic and the results of PCR negative, discharge at 48h post birth can be considered if the necessary conditions are met for adequate monitoring at home and immediate access to the hospital." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "GH, genital herpes; HSV, herpes simplex virus; NH, neonatal herpes; PCR, polymerase chain reaction." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factor \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category of genital herpes infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Greater risk if first episode of GH (primary or non-primary) compared to recurrent GH - The risk of NH is 55% in primary GH, 25% in non-primary first-episode GH, and drops to 2% in recurrent GH<a class="elsevierStyleCrossRef" href="#bib0250">10</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maternal HSV serologic status \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- The risk is greatest in primary GH, as there is no pre-existing immunity. This is especially true if infection occurs in the last 6 weeks of gestation, as there may not be sufficient time for the development and transplacental transfer of maternal protective antibodies<a class="elsevierStyleCrossRef" href="#bib0255">11</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Route of delivery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- There is evidence of the protective effect of caesarean delivery, although transmission is still possible even if the caesarean section is performed before the rupture of membranes<a class="elsevierStyleCrossRef" href="#bib0235">7</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Invasive interventions during labour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Invasive foetal monitoring techniques may facilitate transmission \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of amniorrhexis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- The risk of transmission increases when duration of amniorrhexis >4h - Caesarean delivery seems to reduce the risk of transmission even if the duration of amniorrhexis >4h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Herpes simplex virus type \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- HSV-1 is usually shed when there are genital lesions - HSV-2 shedding may be intermittent and occur even in the absence of lesions, so that transmission frequently occurs in asymptomatic HSV-2 infections<a class="elsevierStyleCrossRef" href="#bib0250">10</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HSV detection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- By means of PCR of swab of vaginal mucosa or lesions, where present \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1817933.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Risk factors for neonatal herpes." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "GH, genital herpes; HSV, herpes simplex virus; PCR, polymerase chain reaction." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Viral detection test (PCR) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Serology (HSV-1 antibodies) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Serology (HSV-2 antibodies) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Classification of infection by HSV \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">HSV-1 detection</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First episode, primary GH by HSV-1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First episode non-primary GH by HSV-1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative or positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recurrent GH by HSV-1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">HSV-2 detection</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First episode, primary GH by HSV-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First episode non-primary GH by HSV-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative or positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recurrent GH by HSV-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1817934.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of the type of genital herpes based on the results of lesion swab viral detection tests and serologic tests (type-specific)." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CNS, central nervous system; HSV, herpes simplex virus." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of infection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intrauterine infection (5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Severe and rare form. It is mainly associated to primary infection by HSV during gestation - The diagnosis is based on the presence of obvious signs of infection in the newborn and the detection of HSV in the first 24h of life - The classic triad of skin, CNS and eye involvement is only found in 1 out of 3 cases. Skin involvement is nearly always present at birth with active lesions or scabs. Approximately 2/3 of patients have CNS involvement (microcephaly, ventriculomegaly, porencephaly, calcifications or haemorrhagic stroke). Eye involvement (chorioretinitis, microphthalmia and cataracts) occurs in 40%. Other manifestations include liver involvement (35%) and bone abnormalities (15%) - The mortality in this form is nearly 45%. Psychomotor retardation is common in survivors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perinatal infection (85%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Clinical forms</td><td class="td" title="table-entry " align="left" valign="top">Localised skin, eyes or mouth disease (45%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Usually presents between 10 and 12 days of life - Skin lesions are present in more than 80% of cases, usually vesicles or ulcers. There may be lesions in the mouth (ulcers) or eyes (conjunctivitis, blepharoconjunctivitis, keratitis and, less frequently, uveitis and acute retinal necrosis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Postnatal infection (10%)</td><td class="td" title="table-entry " align="left" valign="top">Localised CNS disease (30–35%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Later onset, generally between 16 and 19 days of life, although it may manifest as late as the 6th week post birth - The clinical manifestations are often nonspecific and may include irritability, lethargy, food refusal, hypothermia or fever. Some patients present with a bulging fontanelle and/or focal or generalised tonic-clonic seizures - Up to 35% of patients do not develop skin lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disseminated disease (25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Defined by the involvement of several organs, such as the skin, eyes, liver, lungs, CNS or adrenal glands - The newborn develops a sepsis-like presentation with pneumonia and/or hepatitis, usually at 10–12 days of life - This may progress to severe respiratory failure, liver failure or disseminated intravascular coagulopathy, which account for the mortality in these patients - CNS involvement is also present in 60–75% of patients - Only 60% of patients develop a vesicular rash during the course of disease \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1817932.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Forms of neonatal infection by HSV.<a class="elsevierStyleCrossRefs" href="#bib0295">19–25</a>" ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CNS, central nervous system; CSF, cerebrospinal fluid; HSV, herpes simplex virus; PCR, polymerase chain reaction." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Virology tests in newborns with suspected infection by HSV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surface swabs (conjunctivae, mouth, nasopharynx or rectum) for PCR±viral culture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Swabbing or scraping of lesions in skin or mucosa for PCR±viral culture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCR of CSF for detection of HSV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCR of whole blood for detection of HSV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Tests for assessment of organ involvement in newborns with confirmed infection by HSV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood tests: complete blood count, coagulation, blood gases and chemistry panel including determination of transaminase, total and direct bilirubin, electrolyte, urea and creatinine levels \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CSF analysis—cell count and chemistry \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ophthalmological examination \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neuroimaging \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Electroencephalogram (in case of suspected CNS involvement) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal ultrasound (in case of gastrointestinal manifestations, hepatitis or liver failure) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chest X-ray (in case of respiratory manifestations) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Echocardiogram (in case of myocardial dysfunction) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal X-ray (in case of gastrointestinal manifestations) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1817937.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Diagnosis and evaluation of neonatal infection by HSV." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "NMDAr, N-methyl-d-aspartate receptor; IV, intravenous; CNS, central nervous system; CSF, cerebrospinal fluid; HSV, herpes simplex virus; PCR, polymerase chain reaction." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial disease \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic CSF tests \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Development of new neurologic symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Any form \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- HSV PCR of CSF - Antibodies against neuronal cell-surface antibodies in serum and CSF (mainly anti-NMDAr)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Early initiation of IV acyclovir - If HSV is confirmed by isolation from CSF or worsening of CSF analysis findings compared to previous tests, completion of IV treatment is recommended.<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Recurrence of skin, eyes and mouth disease without new neurologic manifestations</td><td class="td" title="table-entry " align="left" valign="top">Previous history of localised CNS or disseminated disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- HSV PCR of CSF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Early initiation of IV acyclovir - If HSV is confirmed by isolation from CSF or worsening of CSF analysis findings compared to previous tests, completion of IV treatment is recommended<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> - If CNS involvement is ruled out and patient is afebrile and in good general health, it is possible to switch to oral treatment (20mg/kg per dose every 6h) for a total course of 5–7 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous history of skin, eyes and mouth disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Consider HSV PCR of CSF on case-to-case basis<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- If lumbar puncture is performed, we recommend initiating treatment with IV acyclovir and following the sequence described above - If lumbar puncture is not performed, oral acyclovir may be considered as an alternative to intravenous treatment, and given at doses of 20mg/kg every 6h for 5–7 days \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1817936.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "We recommend ordering this test in cases with negative results of HSV PCR of CSF." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "The appropriateness of lumbar puncture for assessment of HSV in CSF will be determined on a case-to-case basis based on age, the condition of the patient, history of recurrence and adherence to suppressive therapy." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "The recommendations for treatment with IV acyclovir are detailed in the Treatment section of this article. The dose of acyclovir from age 3 months is 10–15mg/kg every 8h delivered intravenously." ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for the management of recurrent disease in patients undergoing suppressive therapy with acyclovir." ] ] 6 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CNS, central nervous system; HSV, herpes simplex virus." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Form of disease \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality before introduction of antiviral therapy (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality with low-dose acyclovir treatment (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality with high-dose acyclovir treatment (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors for mortality \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disseminated disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lethargy at diagnosis, severe hepatitis grave, coma, disseminated intravascular coagulation, preterm birth and pneumonitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CNS localised disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Preterm birth, lethargy, seizures at treatment initiation and coma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Skin, eyes and mouth disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1817931.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Mortality at age 1 year by form of neonatal infection by HSV.<a class="elsevierStyleCrossRefs" href="#bib0310">22,33,40</a>" ] ] 7 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at7" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CNS, central nervous system; CSF, cerebrospinal fluid; HSV, herpes simplex virus; PCR, polymerase chain reaction." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Localised CNS disease and disseminated disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Delayed diagnosis and late initiation of treatment (delays are associated with progression of skin, eyes and mouth disease to disseminated disease and with increased mortality) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Plasma viral load is associated with mortality, but not with neurologic outcome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Persistence of positive detection of HSV by PCR of CSF after 3 weeks of antiviral therapy in patients with CNS involvement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Lack of suppressive therapy is associated with an increased recurrence of mucocutaneous lesions and poorer neurologic outcomes in patients with CNS involvement<a class="elsevierStyleCrossRefs" href="#bib0360">32,33</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- There is no evidence of an association between HSV type and disease outcome<a class="elsevierStyleCrossRefs" href="#bib0310">22,28,39</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1817935.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Prognostic factors that predict a poor outcome of neonatal infection by HSV." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global estimates of prevalent and incident herpes simplex type 2 infections in 2012" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.J. Looker" 1 => "A.S. Magaret" 2 => "K.M.E. Turner" 3 => "P. Vickerman" 4 => "S.L. Gottlieb" 5 => "L.M. Newman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0114989" "Revista" => array:5 [ "tituloSerie" => "PLOS ONE" "fecha" => "2015" "volumen" => "10" "paginaInicial" => "e114989" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25608026" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0210" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genital herpes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.W. Gnann" 1 => "R.J. 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The Spanish Society of Paediatric Infectious Diseases guidelines on the prevention, diagnosis and treatment of neonatal herpes simplex infections

Guía de la Sociedad Española de Infectología Pediátrica sobre prevención, diagnóstico y tratamiento de la infección neonatal por virus herpes simplex

Working Group on Neonatal Infection by Herpes Simplex Virus of the Sociedad Española de Infectología Pediátrica ◊

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    "titulo" => "The Spanish Society of Paediatric Infectious Diseases guidelines on the prevention&#44; diagnosis and treatment of neonatal herpes simplex infections"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Management of asymptomatic newborns delivered vaginally or by caesarean section and with mothers with genital lesions at the time of delivery&#46; Before implementing this algorithm&#44; the clinician should verify in collaboration with the microbiologist that the necessary techniques are available and the turnaround times are adequate&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#165;</span>The diagnostic evaluation and treatment will be performed earlier if the newborn presents signs of infection by HSV&#46; Some experts recommend collection of specimens and initiation of treatment immediately after delivery in case of prolonged rupture of membranes or preterm birth&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#36;</span>If the newborn is asymptomatic and the results of PCR negative&#44; discharge at 48<span class="elsevierStyleHsp" style=""></span>h post birth can be considered if the necessary conditions are met for adequate monitoring at home and immediate access to the hospital&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Infection by herpes simplex virus type 1 &#40;HSV-1&#41; and type 2 &#40;HSV-2&#41; is highly prevalent worldwide and encompasses a broad range of pathology&#46; Up to 67&#37; of the global population is infected by one of these two viruses&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The first episode of genital infection is labelled <span class="elsevierStyleItalic">primary genital herpes &#40;GH&#41;</span> and may be caused by HSV-1 or HSV-2&#46; When an additional episode is caused by the other type&#44; it is referred to as <span class="elsevierStyleItalic">non-primary first episode GH</span>&#46; New episodes by the same type of the virus are known as <span class="elsevierStyleItalic">recurrent GH</span>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">These viruses may be vertically transmitted to the newborn&#46; Neonatal herpes infection &#40;neonatal herpes &#91;NH&#93;&#41; is rare&#44; but it must be diagnosed correctly and treated at an early stage&#46; In recent years&#44; there have been advances in the diagnosis and treatment of this disease&#44; so this document provides and updated guideline for its multidisciplinary management&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Genital herpes</span><p id="par0020" class="elsevierStylePara elsevierViewall">The type involved most frequently in GH worldwide is HSV-2&#46; The prevalence of HSV-1 is increasing in many countries&#44; such as the United States&#44; where it is now the most frequent cause of new cases of GH&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In Spain&#44; the incidence of genital infections by HSV has increased in recent years&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a> Type 2 has been historically the type isolated most frequently from genital samples&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a> a trend that continues today&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;5</span></a> The seroprevalence of HSV-2 infection in adults is 5&#8211;10&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The risk factors for GH include&#58; female sex&#44; low socioeconomic status&#44; genital coinfection&#44; years of sexual activity and large number of sexual partners&#46; Based on data from the medical literature of the United States&#44; the overall risk of having a first episode of GH during pregnancy is 4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> Also&#44; of all pregnant women with a previous history of symptomatic GH by HSV-2&#44; 75&#37; have at least one episode of recurrent GH during pregnancy&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> The risk of recurrence is lower in women with GH caused by HSV-1&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The identification of NH is frequently challenging&#46; In up to 80&#37; of cases of mother-to-child vertical transmission&#44; there is no previous history of GH&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> although genital viral shedding around the time of delivery&#44; whether symptomatic or asymptomatic&#44; is necessary for transmission&#46; Between 0&#46;2&#37; and 0&#46;39&#37; of pregnant women shed HSV in the genital region during the peripartum period&#44; independently of their personal history of GH&#44; and this prevalence increases to 0&#46;77&#8211;1&#46;4&#37; in women with a history of recurrent GH&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> Viral shedding usually lasts 2 or 3 weeks after a primary GH episode&#44; although it can persist for up to 2 or 3 months&#44; is shorter in non-primary GH episodes&#44; and intermittent in recurrent episodes&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Neonatal herpes</span><p id="par0040" class="elsevierStylePara elsevierViewall">Neonatal herpes is rare in developed countries&#44; with an incidence that ranges between 1&#46;65 and 3&#46;2 cases per 100<span class="elsevierStyleHsp" style=""></span>000 live births in European countries like the Netherlands or Switzerland&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> In other countries there has been a recent increase in incidence&#44; for instance&#44; the incidence in the United Kingdom recently reached 17&#46;5 cases per 100<span class="elsevierStyleHsp" style=""></span>000 births&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> For reasons that remain unclear&#44; the incidence of NH has historically been greater in the United States compared to the European average&#44; ranging between 4 and 33 cases per 100<span class="elsevierStyleHsp" style=""></span>000 live births&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Both HSV-1 and HSV-2 cause disease in the neonatal period&#44; although the proportion of cases caused by either virus varies between case series&#44; reflecting the epidemiology of GH in the geographical area or the time period of the study&#46; Type 2 is the most frequent cause of NH in developing countries&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> The incidence of HSV-1 has increased in developed countries&#44; and HSV-1 is now the most prevalent cause of NH in some countries&#44; including Australia and the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the risk factors for NH&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Infection by herpes simplex virus during pregnancy</span><p id="par0055" class="elsevierStylePara elsevierViewall">The diagnosis of GH in pregnant women is based on history taking and a physical examination&#44; and it must be confirmed by laboratory tests&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical picture</span><p id="par0060" class="elsevierStylePara elsevierViewall">The clinical picture is characterised by the formation of lesions &#40;vesicles that progress to pustules and eventually ulcers&#41;&#44; usually painful&#44; in the genital tract and adjacent areas&#46; Primary infection may manifest with general malaise&#44; dysuria and inguinal lymphadenopathy&#46; However&#44; the first episode of GH may be asymptomatic in up to 2&#47;3 of women&#46; The presentation of recurrent GH is milder&#44; although it is usually preceded by prodromal manifestations such as genital itching&#44; burning or pain&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Laboratory diagnosis</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">First episode of genital herpes during pregnancy</span><p id="par0065" class="elsevierStylePara elsevierViewall">First episodes of GH can be primary or non-primary&#46; Viral detection tests by polymerase chain reaction &#40;PCR&#41; should be performed in samples of ulcer secretions or vesicle fluid collected by swabbing&#46; Polymerase chain reaction is sensitive enough for testing of samples from any type of lesion and is currently the gold standard where available&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> The technique used should be type-specific PCR &#40;for HSV-1 and -2&#41;&#46; Serological tests for HSV &#40;specific antibodies to HSV-1 and 2&#41; at the time of diagnosis allows the classification of maternal GH infection into primary&#44; first-episode non-primary or recurrent infection &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a> It may take up to 6 weeks from primary infection for IgG antibodies to become detectable&#46; Serological testing for detection of IgM antibodies is not recommended in clinical practice&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In women with genital ulcers that are highly suggestive of GH but with negative HSV PCR results&#44; antibody testing should be repeated 6 weeks later&#46; If testing evinces seroconversion&#44; the episode should be diagnosed as primary infection&#46; If testing does not reveal seroconversion&#44; it is unlikely that the ulcer was caused by GH&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pregnant women with recurrent genital herpes</span><p id="par0080" class="elsevierStylePara elsevierViewall">In women with a previous history of confirmed GH &#40;PCR&#41;&#44; further diagnostic testing is unnecessary&#46; There is no evidence that repeated testing by PCR to detect asymptomatic shedding during pregnancy or at the time of delivery helps prevent vertical transmission&#44; and this strategy is therefore not indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">However&#44; if a pregnant woman has compatible lesions and reports a history of previous episodes but these episodes were not confirmed by diagnostic tests&#44; performance of PCR and antibody tests is indicated to confirm the diagnosis&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment of herpes simplex virus infection during pregnancy&#46; Strategies for prevention of mother-to-child transmission &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main goal of GH treatment during pregnancy is prevention of mother-to-child transmission&#46; The best measures currently available to this end are caesarean delivery in mothers that have herpetic lesions and the reduction of viral shedding by administration of antiviral agents to pregnant women with active GH in the last few weeks of pregnancy&#46; The FDA has classified acyclovir and valacyclovir as category B drugs&#44; but their use is considered safe in any trimester of gestation&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">15</span></a> Since there is less evidence on valacyclovir&#44; some guidelines recommend avoiding this drug in the first trimester&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a> Suppressive therapy has proven effective in reducing recurrence and the need for caesarean delivery&#44; although the evidence published to date has not demonstrated a reduction in the risk of NH<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Primary genital herpes during gestation</span><p id="par0095" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment</span>&#58; Oral acyclovir at 400<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>h or oral valacyclovir at 1<span class="elsevierStyleHsp" style=""></span>g every 12<span class="elsevierStyleHsp" style=""></span>h for 7&#8211;10 days&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Route of delivery</span>&#58; Whenever primary HSV infection is diagnosed during labour&#44; a caesarean delivery will be performed as soon as possible&#44; regardless of the duration of amniorrhexis&#46; An elective caesarean delivery will be performed in every pregnant woman that has a primary episode of GH within 6 weeks from delivery&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;17&#44;18</span></a></p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Recurrent genital herpes during gestation</span><p id="par0110" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment</span>&#58; Consider administration of oral acyclovir at 400<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>h or oral valacyclovir at 500<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h for 3&#8211;5 days&#46; In general&#44; treatment is only necessary if the mother has significant symptoms or if the lesions appear when the time of delivery is approaching&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;17&#44;18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Route of delivery</span>&#58; Elective caesarean delivery is only indicated in patients that have an outbreak or prodromal symptoms during labour&#44; regardless of the duration of amniorrhexis&#46; An episode of GH at any other time of the pregnancy is not an indication for caesarean delivery&#46; In case of vaginal delivery&#44; invasive procedures &#40;such as continuous foetal heart rate monitoring with scalp electrodes or foetal blood microsampling&#41; and prolonged rupture of membranes should be avoided&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Suppressive therapy</span><p id="par0125" class="elsevierStylePara elsevierViewall">In pregnant women with a first episode of GH &#40;primary or non-primary&#41; or with recurrent GH and at least one symptomatic outbreak during pregnancy&#44; suppressive therapy with oral acyclovir at 400<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>h or valacyclovir at 500<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h is recommended starting from 36 weeks&#8217; gestation through delivery&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;17&#44;18</span></a> In women at risk of preterm delivery&#44; use of suppressive antivirals may be considered at an earlier gestational age when the risk of preterm birth due to short cervix or dynamic changes is identified&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Women with HIV infection and a history of GH &#40;even those without episodes during gestation&#41; should be offered suppressive therapy starting at 32 weeks&#8217; gestation due to the increased risk of preterm delivery and of HIV transmission associated with HSV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Genital herpes in pregnant women with premature rupture of membranes at more than 37 weeks&#8217; gestation</span><p id="par0135" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">In cases of <span class="elsevierStyleItalic">maternal primary infection</span>&#44; the risk of NH is very high&#44; but there is little evidence on the optimal management of these cases&#46; The management will be individualised and based on gestational age&#46; If the decision is to end the pregnancy immediately&#44; the child will be delivered by caesarean section&#46; If a watchful waiting approach is chosen&#44; the mother will be given intravenous acyclovir &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 8<span class="elsevierStyleHsp" style=""></span>h&#41; for a maximum of 7&#8211;10 days&#44; and suppressive therapy until delivery may be considered&#46; If the time elapsed between onset of GH and delivery is less than 6 weeks&#44; delivery by caesarean section is preferable&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">In cases of <span class="elsevierStyleItalic">maternal recurrent infection</span>&#44; the mother will receive oral antiviral therapy and the followup will be the same as would be in case of premature rupture of membranes&#46; If the lesions have not resolved by the time ending the pregnancy is indicated&#44; the child will be delivered by caesarean section&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;17</span></a></p></li></ul></p></span></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Neonatal herpes&#58; disease forms</span><p id="par0150" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> describes the 3 forms of NH associated to perinatal and postnatal infection&#46; This classification has significant implications for treatment&#44; and each of the forms has a different prognosis&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Diagnosis of infection in the newborn</span><p id="par0155" class="elsevierStylePara elsevierViewall">The initial manifestations of NH may be subtle and nonspecific&#46; Its presentation may be confused with other diseases&#44; mainly bacterial infections &#40;sepsis or meningitis&#41; or viral infections &#40;especially infection by enterovirus or parechovirus&#41;&#46; Early diagnosis and treatment of NH requires a high level of suspicion&#44; especially in the absence of skin lesions&#46; We recommend ruling out NH infection in newborns with lesions in the skin or mucosae&#44; central nervous system &#40;CNS&#41; involvement or a sepsis-like picture of unexplained aetiology&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">When NH is suspected&#44; the newborn should undergo comprehensive viral testing &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The confirmation of the diagnosis through laboratory methods mainly involves the detection of HSV by PCR&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Polymerase chain reaction for detection of HSV in cerebrospinal fluid &#40;CSF&#41; is the gold standard for diagnosis due to the higher sensitivity of viral culture of this type of sample&#46; In the current literature&#44; the reported sensitivity of PCR for detection of HSV in CSF ranges between 75&#37; and 100&#37;&#44; while the reported specificity between ranges between 71&#37; and 100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">26&#44;27</span></a> In clinical practice&#44; false positives for HSV are extremely rare&#46; Polymerase chain reaction for detection of HSV in blood samples is also highly sensitive and is recommended for the diagnostic evaluation of newborns with suspected NH of any form&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Lumbar puncture should be performed in every newborn with suspected NH&#44; even in cases where isolated skin involvement is likely&#46; The presence of blood or elevated protein levels in CSF may interfere with PCR and lead to false negative results&#46; Polymerase chain reaction may also yield false negative results if lumbar puncture is performed in the early stages of disease &#40;first 3 days&#41; or after several days of antiviral therapy&#46; If the initial PCR test is negative and CNS involvement is suspected&#44; a repeat PCR should be performed in the first week since onset&#44; and antiviral therapy maintained until the results become available&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The characteristic findings of CSF analysis are pleocytosis with a predominance of mononuclear cells and moderate elevation of protein and glucose levels&#46; The findings of CSF analysis may be normal in the early stages of CNS involvement&#46; The presence of red blood cells in CSF does not seem characteristic of HSV-related neonatal meningoencephalitis&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Neuroimaging tests should be performed in every newborn with NH&#44; and the gold standard is magnetic resonance imaging &#40;MRI&#41;&#46; Involvement is usually diffuse in newborns with HSV encephalitis&#46; The usual course of CNS involvement is oedema that progresses to cystic encephalomalacia&#46; Neuroimaging findings may be normal at first&#44; and diffusion-weighted MRI is the most sensitive technique for the early detection of CNS changes&#46; Magnetic resonance imaging can be used on completion of antiviral treatment to assess the level of brain damage&#46; The diagnostic yield of computed tomography is lower compared to MRI&#46; Head ultrasound offers the advantage of allowing followup through serial examinations&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Although regular or nearly regular focal or multifocal epileptiform discharges are the typical encephalographic presentation&#44; the encephalographic pattern in the acute phase of neonatal encephalitis due to HSV can include a variety of features&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a> The presence of focal or unilateral abnormalities associated to clinical signs of encephalitis is highly suggestive of HSV infection&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The evaluation of the extent of dissemination is key to provide adequate treatment in the early stages of disease &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Chest radiography may reveal lung involvement&#44; characterised by a diffuse interstitial pattern that may progress to pneumonitis with alveolar haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a> In cases of hepatitis&#44; abdominal ultrasound may reveal hepatomegaly with fine nodular patterns in the liver parenchyma&#44; splenomegaly&#44; signs of portal hypertension and ascites&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Treatment</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Treatment of acute infection</span><p id="par0200" class="elsevierStylePara elsevierViewall">Treatment of NH includes the usual life support measures used in any septic process in newborns&#44; management of potential complications &#40;seizures&#44; in which it is essential to avoid hypoglycaemia&#44; disseminated intravascular coagulation&#44; bacterial superinfection&#44; etc&#46;&#41; and antiviral therapy&#46; High-dose acyclovir &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 8<span class="elsevierStyleHsp" style=""></span>h&#44; intravenously&#44; adjusted based on renal function&#41; is the first-line antiviral for all forms of disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;24&#44;32</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In most cases&#44; clinical suspicion of infection by HSV is sufficient indication for treatment&#46; Early initiation of acyclovir improves morbidity and mortality outcomes for HSV infection&#46; We recommend monitoring renal function and neutrophil counts during treatment&#46; In cases where acyclovir is contraindicated&#44; ganciclovir of foscarnet can be used&#44; also delivered intravenously&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Treatment should last 14 days in the skin&#44; eyes and mouth form and 21 days in cases of localised CNS involvement or disseminated disease&#46; Treatment may be discontinued after the patient shows a favourable response&#44; although in cases of CNS involvement&#44; PCR should be performed to verify negativization&#44; which is usually accompanied by the normalisation of the CNS analysis findings&#46; In case the virus is detected in CSF&#44; treatment with acyclovir will continue accompanied by weekly testing of the CSF&#44; and suspended once the PCR results become negative&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> Some authors consider plasma viral levels undetectable by PCR a marker of resolution in severe or disseminated forms of disease&#44; and continued treatment in their patients as long as viral detection tests were positive&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In case of keratitis and&#47;or conjunctivitis&#44; the patient should also receive topical treatment &#40;idoxuridine 0&#46;1&#37; solution or ganciclovir 0&#46;15&#37; gel&#41;&#46; If the patient has with mucocutaneous lesions&#44; adequate contact precautions should be followed throughout the hospital stay&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Suppressive treatment&#46; Treatment of recurrent herpes</span><p id="par0220" class="elsevierStylePara elsevierViewall">Following treatment of acute disease&#44; suppressive therapy with acyclovir is recommended for all forms of disease &#40;300<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#47;dose given orally every 8<span class="elsevierStyleHsp" style=""></span>h&#41; for a minimum of 6 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">32&#44;33</span></a> The dose must be adjusted as the patient grows&#44; and the neutrophil count must be monitored&#44; with measurements 2 weeks after treatment initiation and monthly thereafter&#46; Most experts recommend temporary discontinuation of suppressive therapy if the neutrophil count is less than 500<span class="elsevierStyleHsp" style=""></span>cells&#47;mm<span class="elsevierStyleSup">3</span>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Disease recurrence can even occur in the context of suppressive treatment&#46; The current evidence is not sufficient to establish the best course of action in these cases&#46; <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> presents the recommendations of our Working Group&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Management of children exposed to herpes</span><p id="par0230" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> describes the possible scenarios and the protocol for the management of children born to mothers with genital lesions associated with HSV infection at the time of delivery&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">34&#8211;36</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Outcomes of neonatal infection&#46; Patient followup</span><p id="par0235" class="elsevierStylePara elsevierViewall">The mortality rate associated with NH is of approximately 0&#46;8 deaths per 100<span class="elsevierStyleHsp" style=""></span>000 live births&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">37</span></a> Mortality has declined significantly after the introduction of antiviral treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">21&#44;29&#44;35</span></a> Antiviral treatment has not only succeeded in preventing the progression of cutaneous disease&#44; owing to which neurologic outcomes in these patients are currently excellent&#44; but is also associated with significantly improved neurologic outcomes in cases of disseminated disease&#46; The introduction of suppressive therapy has also been a substantial step forward&#44; improving neurologic outcomes in patients with CNS involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;24&#44;33&#44;35&#44;38</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a> presents the prognostic factors for NH&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><p id="par0245" class="elsevierStylePara elsevierViewall">The main sequelae are neurologic impairment &#40;psychomotor retardation&#44; microcephaly&#44; paresis&#44; spasticity&#44; epilepsy&#44; learning disabilities&#41;&#44; ocular impairment &#40;cortical blindness&#44; corneal and chorioretinal scars&#44; optical atrophy&#44; cataracts&#44; acute retinal necrosis and oculomotor disorders&#41; and hearing impairment &#40;neurosensory hearing loss&#41;&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">We recommend that the followup of patients with NH be performed by a multidisciplinary team&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">33&#44;35</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Recent evidence has emerged that in cases of HSV infection with CNS involvement&#44; the infection can trigger autoimmune encephalopathy&#44; in most cases with presence of anti-N-methyl-<span class="elsevierStyleSmallCaps">d</span>-aspartate receptor antibodies &#40;anti-NMDAr Abs&#41;&#46; Up to 20&#37; of relapses in patients with CNS infection by HSV may be immune-mediated&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> The encephalopathy usually develops weeks or months after the acute infection by HSV&#44; and the most frequent feature in young children is choreoathetosis&#44; with other frequent manifestations including decreased level of consciousness and convulsive seizures&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> Patients with this clinical presentation should be assessed with determination of neuronal cell-surface antibodies in serum and CSF &#40;mainly anti-NMDAr Abs&#41;&#46; Some authors recommend starting empiric immunotherapy in patients with these symptoms and negative results of CSF PCR for HSV while awaiting the antibody results&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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              "titulo" => "Epidemiology"
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          "titulo" => "Infection by herpes simplex virus during pregnancy"
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              "titulo" => "Treatment of herpes simplex virus infection during pregnancy&#46; Strategies for prevention of mother-to-child transmission &#40;Table 3&#41;"
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                  "identificador" => "sec0055"
                  "titulo" => "Primary genital herpes during gestation"
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                  "titulo" => "Recurrent genital herpes during gestation"
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                  "titulo" => "Genital herpes in pregnant women with premature rupture of membranes at more than 37 weeks&#8217; gestation"
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          "identificador" => "sec0075"
          "titulo" => "Neonatal herpes&#58; disease forms"
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          "titulo" => "Diagnosis of infection in the newborn"
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              "titulo" => "Suppressive treatment&#46; Treatment of recurrent herpes"
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          "titulo" => "Management of children exposed to herpes"
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          "titulo" => "Outcomes of neonatal infection&#46; Patient followup"
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    "fechaRecibido" => "2017-12-24"
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            2 => "Mother-to-child transmission prevention"
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            0 => "Infecci&#243;n neonatal"
            1 => "Virus herpes simplex"
            2 => "Prevenci&#243;n de la transmisi&#243;n maternoinfantil"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neonatal herpes simplex virus infections are rare&#44; but are associated with significant morbidity and mortality&#46; Most newborns acquire herpes simplex virus infection in the peripartum period&#46; For peripartum transmission to occur&#44; women must be shedding the virus in their genital tracts symptomatically or asymptomatically around the time of delivery&#46; There are evidence-based interventions in pregnancy to prevent the transmission to the newborn&#46; Caesarean section should be performed in the presence of herpetic lesions&#44; and antiviral prophylaxis in the last weeks of pregnancy is recommended to suppress genital tract herpes simplex virus at the time of delivery&#46; The diagnosis and early treatment of neonatal herpes simplex virus infections require a high index of suspicion&#44; especially in the absence of skin lesions&#46; It is recommended to rule out herpes simplex virus infections in those newborns with mucocutaneous lesions&#44; central nervous system involvement&#44; or septic appearance&#46; The prognosis of newborns with skin&#44; eye&#44; and&#47;or mouth disease in the high-dose acyclovir era is very good&#46; Antiviral treatment not only improves mortality rates in disseminated and central nervous system disease&#44; but also improves the rates of long-term neurodevelopmental impairment in the cases of disseminated disease&#46; Interestingly&#44; a 6-month suppressive course of oral acyclovir following the acute infection has improved the neurodevelopmental prognosis in patients with CNS involvement&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La infecci&#243;n herp&#233;tica neonatal es una entidad muy poco frecuente pero que se asocia a una alta morbimortalidad&#46; La mayor parte de los neonatos afectos adquieren la infecci&#243;n por virus herpes simplex en el periodo periparto&#46; Para que ocurra esta transmisi&#243;n es necesaria la excreci&#243;n viral genital&#44; con o sin s&#237;ntomas&#44; alrededor del momento del parto&#46; Existen intervenciones basadas en la evidencia para prevenir la transmisi&#243;n del virus herpes simplex al reci&#233;n nacido&#46; La realizaci&#243;n de una ces&#225;rea en presencia de lesiones herp&#233;ticas&#44; y la disminuci&#243;n de la excreci&#243;n viral administrando en las &#250;ltimas semanas del embarazo tratamiento antiviral a gestantes con herpes genital activo&#44; son las mejores medidas preventivas de las que se dispone&#46; El diagn&#243;stico y tratamiento precoz del herpes neonatal requiere de un alto &#237;ndice de sospecha&#44; sobre todo en ausencia de lesiones cut&#225;neas&#46; Se recomienda descartar la infecci&#243;n por herpes neonatal en aquellos reci&#233;n nacidos con lesiones cutaneomucosas&#44; afectaci&#243;n del sistema nervioso central o cuadro s&#233;ptico de origen no aclarado&#46; El pron&#243;stico de los neonatos con enfermedad cut&#225;nea en la era del aciclovir a dosis altas es excelente&#46; El tratamiento antiviral disminuye la mortalidad de las formas diseminadas y con afectaci&#243;n exclusiva del sistema nervioso central&#44; pero tambi&#233;n mejora el pron&#243;stico neurol&#243;gico en los casos de enfermedad diseminada&#46; De forma notable&#44; la introducci&#243;n del tratamiento supresor con aciclovir oral durante los meses siguientes a la infecci&#243;n aguda ha mejorado el pron&#243;stico neurol&#243;gico en los pacientes con afectaci&#243;n del sistema nervioso central&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0025"><a class="elsevierStyleCrossRef" href="#sec0115">Appendix A</a> lists the names of all the authors of the article&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Grupo de Trabajo de Infecci&#243;n Neonatal por virus herpes simplex de la Sociedad Espa&#241;ola de Infectolog&#237;a Pedi&#225;trica&#46; Gu&#237;a de la Sociedad Espa&#241;ola de Infectolog&#237;a Pedi&#225;trica sobre prevenci&#243;n&#44; diagn&#243;stico y tratamiento de la infecci&#243;n neonatal por virus herpes simplex&#46; An Pediatr &#40;Barc&#41;&#46; 2018&#59;89&#58;64&#46;</p>"
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            "apendice" => "<p id="par0270" class="elsevierStylePara elsevierViewall">Coordinators &#40;in alphabetical order&#41;</p> <p id="par0275" class="elsevierStylePara elsevierViewall">Writers &#40;in alphabetical order&#41;</p>"
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            "titulo" => "Authors of the article"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Management of asymptomatic newborns delivered vaginally or by caesarean section and with mothers with genital lesions at the time of delivery&#46; Before implementing this algorithm&#44; the clinician should verify in collaboration with the microbiologist that the necessary techniques are available and the turnaround times are adequate&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#165;</span>The diagnostic evaluation and treatment will be performed earlier if the newborn presents signs of infection by HSV&#46; Some experts recommend collection of specimens and initiation of treatment immediately after delivery in case of prolonged rupture of membranes or preterm birth&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#36;</span>If the newborn is asymptomatic and the results of PCR negative&#44; discharge at 48<span class="elsevierStyleHsp" style=""></span>h post birth can be considered if the necessary conditions are met for adequate monitoring at home and immediate access to the hospital&#46;</p>"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">GH&#44; genital herpes&#59; HSV&#44; herpes simplex virus&#59; NH&#44; neonatal herpes&#59; PCR&#44; polymerase chain reaction&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category of genital herpes infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Greater risk if first episode of GH &#40;primary or non-primary&#41; compared to recurrent GH<br>- The risk of NH is 55&#37; in primary GH&#44; 25&#37; in non-primary first-episode GH&#44; and drops to 2&#37; in recurrent GH<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maternal HSV serologic status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- The risk is greatest in primary GH&#44; as there is no pre-existing immunity&#46; This is especially true if infection occurs in the last 6 weeks of gestation&#44; as there may not be sufficient time for the development and transplacental transfer of maternal protective antibodies<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Route of delivery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- There is evidence of the protective effect of caesarean delivery&#44; although transmission is still possible even if the caesarean section is performed before the rupture of membranes<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Invasive interventions during labour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Invasive foetal monitoring techniques may facilitate transmission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of amniorrhexis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- The risk of transmission increases when duration of amniorrhexis &#62;4<span class="elsevierStyleHsp" style=""></span>h<br>- Caesarean delivery seems to reduce the risk of transmission even if the duration of amniorrhexis &#62;4<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Herpes simplex virus type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- HSV-1 is usually shed when there are genital lesions<br>- HSV-2 shedding may be intermittent and occur even in the absence of lesions&#44; so that transmission frequently occurs in asymptomatic HSV-2 infections<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HSV detection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- By means of PCR of swab of vaginal mucosa or lesions&#44; where present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Risk factors for neonatal herpes&#46;</p>"
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      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at2"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">GH&#44; genital herpes&#59; HSV&#44; herpes simplex virus&#59; PCR&#44; polymerase chain reaction&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Viral detection test &#40;PCR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Serology &#40;HSV-1 antibodies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Serology &#40;HSV-2 antibodies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Classification of infection by HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">HSV-1 detection</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First episode&#44; primary GH by HSV-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First episode non-primary GH by HSV-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative or positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent GH by HSV-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">HSV-2 detection</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First episode&#44; primary GH by HSV-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First episode non-primary GH by HSV-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative or positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent GH by HSV-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Classification of the type of genital herpes based on the results of lesion swab viral detection tests and serologic tests &#40;type-specific&#41;&#46;</p>"
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      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at3"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CNS&#44; central nervous system&#59; HSV&#44; herpes simplex virus&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intrauterine infection &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Severe and rare form&#46; It is mainly associated to primary infection by HSV during gestation<br>- The diagnosis is based on the presence of obvious signs of infection in the newborn and the detection of HSV in the first 24<span class="elsevierStyleHsp" style=""></span>h of life<br>- The classic triad of skin&#44; CNS and eye involvement is only found in 1 out of 3 cases&#46; Skin involvement is nearly always present at birth with active lesions or scabs&#46; Approximately 2&#47;3 of patients have CNS involvement &#40;microcephaly&#44; ventriculomegaly&#44; porencephaly&#44; calcifications or haemorrhagic stroke&#41;&#46; Eye involvement &#40;chorioretinitis&#44; microphthalmia and cataracts&#41; occurs in 40&#37;&#46; Other manifestations include liver involvement &#40;35&#37;&#41; and bone abnormalities &#40;15&#37;&#41;<br>- The mortality in this form is nearly 45&#37;&#46; Psychomotor retardation is common in survivors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perinatal infection &#40;85&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Clinical forms</td><td class="td" title="table-entry  " align="left" valign="top">Localised skin&#44; eyes or mouth disease &#40;45&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Usually presents between 10 and 12 days of life<br>- Skin lesions are present in more than 80&#37; of cases&#44; usually vesicles or ulcers&#46; There may be lesions in the mouth &#40;ulcers&#41; or eyes &#40;conjunctivitis&#44; blepharoconjunctivitis&#44; keratitis and&#44; less frequently&#44; uveitis and acute retinal necrosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Postnatal infection &#40;10&#37;&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Localised CNS disease &#40;30&#8211;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Later onset&#44; generally between 16 and 19 days of life&#44; although it may manifest as late as the 6th week post birth<br>- The clinical manifestations are often nonspecific and may include irritability&#44; lethargy&#44; food refusal&#44; hypothermia or fever&#46; Some patients present with a bulging fontanelle and&#47;or focal or generalised tonic-clonic seizures<br>- Up to 35&#37; of patients do not develop skin lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disseminated disease &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-Defined by the involvement of several organs&#44; such as the skin&#44; eyes&#44; liver&#44; lungs&#44; CNS or adrenal glands<br>- The newborn develops a sepsis-like presentation with pneumonia and&#47;or hepatitis&#44; usually at 10&#8211;12 days of life<br>- This may progress to severe respiratory failure&#44; liver failure or disseminated intravascular coagulopathy&#44; which account for the mortality in these patients<br>- CNS involvement is also present in 60&#8211;75&#37; of patients<br>- Only 60&#37; of patients develop a vesicular rash during the course of disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Forms of neonatal infection by HSV&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19&#8211;25</span></a></p>"
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        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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            "identificador" => "at4"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CNS&#44; central nervous system&#59; CSF&#44; cerebrospinal fluid&#59; HSV&#44; herpes simplex virus&#59; PCR&#44; polymerase chain reaction&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1&#46; Virology tests in newborns with suspected infection by HSV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surface swabs &#40;conjunctivae&#44; mouth&#44; nasopharynx or rectum&#41; for PCR<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>viral culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Swabbing or scraping of lesions in skin or mucosa for PCR<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>viral culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PCR of CSF for detection of HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PCR of whole blood for detection of HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2&#46; Tests for assessment of organ involvement in newborns with confirmed infection by HSV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Blood tests&#58; complete blood count&#44; coagulation&#44; blood gases and chemistry panel including determination of transaminase&#44; total and direct bilirubin&#44; electrolyte&#44; urea and creatinine levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CSF analysis&#8212;cell count and chemistry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ophthalmological examination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neuroimaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Electroencephalogram &#40;in case of suspected CNS involvement&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abdominal ultrasound &#40;in case of gastrointestinal manifestations&#44; hepatitis or liver failure&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chest X-ray &#40;in case of respiratory manifestations&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Echocardiogram &#40;in case of myocardial dysfunction&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abdominal X-ray &#40;in case of gastrointestinal manifestations&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Diagnosis and evaluation of neonatal infection by HSV&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">NMDAr&#44; N-methyl-<span class="elsevierStyleSmallCaps">d</span>-aspartate receptor&#59; IV&#44; intravenous&#59; CNS&#44; central nervous system&#59; CSF&#44; cerebrospinal fluid&#59; HSV&#44; herpes simplex virus&#59; PCR&#44; polymerase chain reaction&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic CSF tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Development of new neurologic symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Any form&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- HSV PCR of CSF<br>- Antibodies against neuronal cell-surface antibodies in serum and CSF &#40;mainly anti-NMDAr&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Early initiation of IV acyclovir<br>- If HSV is confirmed by isolation from CSF or worsening of CSF analysis findings compared to previous tests&#44; completion of IV treatment is recommended&#46;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Recurrence of skin&#44; eyes and mouth disease without new neurologic manifestations</td><td class="td" title="table-entry  " align="left" valign="top">Previous history of localised CNS or disseminated disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- HSV PCR of CSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Early initiation of IV acyclovir<br>- If HSV is confirmed by isolation from CSF or worsening of CSF analysis findings compared to previous tests&#44; completion of IV treatment is recommended<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a><br>- If CNS involvement is ruled out and patient is afebrile and in good general health&#44; it is possible to switch to oral treatment &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg per dose every 6<span class="elsevierStyleHsp" style=""></span>h&#41; for a total course of 5&#8211;7 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous history of skin&#44; eyes and mouth disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Consider HSV PCR of CSF on case-to-case basis<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- If lumbar puncture is performed&#44; we recommend initiating treatment with IV acyclovir and following the sequence described above<br>- If lumbar puncture is not performed&#44; oral acyclovir may be considered as an alternative to intravenous treatment&#44; and given at doses of 20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 6<span class="elsevierStyleHsp" style=""></span>h for 5&#8211;7 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1817936.png"
              ]
            ]
          ]
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">We recommend ordering this test in cases with negative results of HSV PCR of CSF&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The appropriateness of lumbar puncture for assessment of HSV in CSF will be determined on a case-to-case basis based on age&#44; the condition of the patient&#44; history of recurrence and adherence to suppressive therapy&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The recommendations for treatment with IV acyclovir are detailed in the <span class="elsevierStyleItalic">Treatment</span> section of this article&#46; The dose of acyclovir from age 3 months is 10&#8211;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 8<span class="elsevierStyleHsp" style=""></span>h delivered intravenously&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the management of recurrent disease in patients undergoing suppressive therapy with acyclovir&#46;</p>"
        ]
      ]
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">CNS&#44; central nervous system&#59; HSV&#44; herpes simplex virus&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Form of disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality before introduction of antiviral therapy &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality with low-dose acyclovir treatment &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality with high-dose acyclovir treatment &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors for mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disseminated disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lethargy at diagnosis&#44; severe hepatitis grave&#44; coma&#44; disseminated intravascular coagulation&#44; preterm birth and pneumonitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CNS localised disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Preterm birth&#44; lethargy&#44; seizures at treatment initiation and coma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Skin&#44; eyes and mouth disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Mortality at age 1 year by form of neonatal infection by HSV&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;33&#44;40</span></a></p>"
        ]
      ]
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        "identificador" => "tbl0035"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at7"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">CNS&#44; central nervous system&#59; CSF&#44; cerebrospinal fluid&#59; HSV&#44; herpes simplex virus&#59; PCR&#44; polymerase chain reaction&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Localised CNS disease and disseminated disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Delayed diagnosis and late initiation of treatment &#40;delays are associated with progression of skin&#44; eyes and mouth disease to disseminated disease and with increased mortality&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Plasma viral load is associated with mortality&#44; but not with neurologic outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Persistence of positive detection of HSV by PCR of CSF after 3 weeks of antiviral therapy in patients with CNS involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Lack of suppressive therapy is associated with an increased recurrence of mucocutaneous lesions and poorer neurologic outcomes in patients with CNS involvement<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">32&#44;33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- There is no evidence of an association between HSV type and disease outcome<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;28&#44;39</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Prognostic factors that predict a poor outcome of neonatal infection by HSV&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:40 [
            0 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "1"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Global estimates of prevalent and incident herpes simplex type 2 infections in 2012"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "K&#46;J&#46; Looker"
                            1 => "A&#46;S&#46; Magaret"
                            2 => "K&#46;M&#46;E&#46; Turner"
                            3 => "P&#46; Vickerman"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0114989"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLOS ONE"
                        "fecha" => "2015"
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                        "paginaInicial" => "e114989"
                        "link" => array:1 [
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                            "web" => "Medline"
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                        ]
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            1 => array:3 [
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                      "titulo" => "Genital herpes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "J&#46;W&#46; Gnann"
                            1 => "R&#46;J&#46; Whitley"
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                    ]
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                  "host" => array:1 [
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            ]
            2 => array:3 [
              "identificador" => "bib0215"
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              "referencia" => array:1 [
                0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Sistema de Informaci&#243;n Microbiol&#243;gica"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:3 [
                        "titulo" => "Centro Nacional de Epidemiolog&#237;a&#46; Instituto de Salud Carlos III&#46; Informe anual del Sistema de Informaci&#243;n Microbiol&#243;gica 2015"
                        "conferencia" => "Madrid"
                        "serieFecha" => "2016"
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            ]
            3 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "4"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Incidencia de infecciones genitales causadas por el virus del herpes tipo 1 &#40;VHS-1&#41; durante el periodo 1995-2003"
                      "autores" => array:1 [
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                          "etal" => false
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                            0 => "J&#46;M&#46; Reina"
                            1 => "O&#46; Guti&#233;rrez"
                            2 => "E&#46; Ruiz de Gopegui"
                            3 => "E&#46; Padilla"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2005"
                        "volumen" => "23"
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                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infecci&#243;n genital por el virus herpes simple&#46; Sistema de Informaci&#243;n Microbiol&#243;gica&#46; Espa&#241;a&#46; A&#241;os 2000-2008"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Centro Nacional de Epidemiolog&#237;a"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Bol Epidemiol Sem"
                        "fecha" => "2011"
                        "volumen" => "19"
                        "paginaInicial" => "1"
                        "paginaFinal" => "17"
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                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Neonatal herpes simplex virus infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;H&#46; James"
                            1 => "D&#46;W&#46; Kimberlin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Infect Dis Clin N Am"
                        "fecha" => "2015"
                        "volumen" => "29"
                        "paginaInicial" => "391"
                        "paginaFinal" => "400"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of neonatal herpes simplex virus infection and exposure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;G&#46; Pinninti"
                            1 => "D&#46;W&#46; Kimberlin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/archdischild-2013-303762"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed"
                        "fecha" => "2014"
                        "volumen" => "99"
                        "paginaInicial" => "F240"
                        "paginaFinal" => "F244"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24589428"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The incidence and presentation of neonatal herpes in a single UK tertiary centre&#44; 2006&#8211;2013"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46; Batra"
                            1 => "P&#46; Davies"
                            2 => "B&#46;N&#46; Manktelow"
                            3 => "C&#46; Smith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/archdischild-2013-305335"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dis Child"
                        "fecha" => "2014"
                        "volumen" => "99"
                        "paginaInicial" => "916"
                        "paginaFinal" => "921"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24919712"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Population-based surveillance of neonatal herpes simplex virus infection in Australia&#44; 1997&#8211;2011"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Study Investigators and Contributors to the Australian Paediatric Surveillance Unit"
                          "etal" => false
                          "autores" => array:4 [
                            0 => "C&#46;A&#46; Jones"
                            1 => "C&#46; Raynes-Greenow"
                            2 => "D&#46; Isaacs"
                            3 => "H&#46;S&#46;V&#46; Neonatal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/ciu381"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2014"
                        "volumen" => "59"
                        "paginaInicial" => "525"
                        "paginaFinal" => "531"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24846638"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Z&#46;A&#46; Brown"
                            1 => "A&#46; Wald"
                            2 => "R&#46;A&#46; Morrow"
                            3 => "S&#46; Selke"
                            4 => "J&#46; Zeh"
                            5 => "L&#46; Corey"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2003"
                        "volumen" => "289"
                        "paginaInicial" => "203"
                        "paginaFinal" => "209"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12517231"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "11"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2018.01.008

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Year/Month	Html	Pdf	Total

2024 November	7	9	16
2024 October	58	50	108
2024 September	86	52	138
2024 August	74	57	131
2024 July	53	40	93
2024 June	66	39	105
2024 May	62	38	100
2024 April	57	43	100
2024 March	56	37	93
2024 February	40	28	68
2024 January	53	19	72
2023 December	76	28	104
2023 November	50	20	70
2023 October	62	30	92
2023 September	37	25	62
2023 August	44	17	61
2023 July	50	42	92
2023 June	64	36	100
2023 May	67	21	88
2023 April	54	19	73
2023 March	97	25	122
2023 February	57	31	88
2023 January	41	36	77
2022 December	96	37	133
2022 November	117	49	166
2022 October	125	52	177
2022 September	45	32	77
2022 August	63	48	111
2022 July	48	50	98
2022 June	45	33	78
2022 May	63	44	107
2022 April	100	41	141
2022 March	104	64	168
2022 February	110	33	143
2022 January	70	34	104
2021 December	53	37	90
2021 November	72	47	119
2021 October	84	79	163
2021 September	60	39	99
2021 August	66	38	104
2021 July	44	33	77
2021 June	58	39	97
2021 May	55	49	104
2021 April	129	87	216
2021 March	60	35	95
2021 February	64	23	87
2021 January	59	27	86
2020 December	56	22	78
2020 November	64	17	81
2020 October	49	20	69
2020 September	61	16	77
2020 August	66	12	78
2020 July	70	21	91
2020 June	65	11	76
2020 May	56	23	79
2020 April	70	15	85
2020 March	62	14	76
2020 February	66	13	79
2020 January	65	21	86
2019 December	94	18	112
2019 November	84	11	95
2019 October	92	17	109
2019 September	85	32	117
2019 August	81	30	111
2019 July	71	19	90
2019 June	84	27	111
2019 May	127	14	141
2019 April	126	28	154
2019 March	68	29	97
2019 February	79	33	112
2019 January	41	11	52
2018 December	57	24	81
2018 November	84	29	113
2018 October	77	31	108
2018 September	51	17	68
2018 June	0	5	5

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